Provider Demographics
NPI:1841799491
Name:GORDON, INETA MARIA (LMT)
Entity Type:Individual
Prefix:
First Name:INETA
Middle Name:MARIA
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:INETA
Other - Middle Name:MARIA
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:460 AVENTURA CT
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6101
Mailing Address - Country:US
Mailing Address - Phone:301-204-7573
Mailing Address - Fax:
Practice Address - Street 1:460 AVENTURA CT
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6101
Practice Address - Country:US
Practice Address - Phone:301-204-7573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMO3207225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty